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Alcohol related disorders

Introduction:

Alcohol use is widely prevalent in Indian society and consequently results in widespread losses in the form of injurious physical health outcomes like cirrhosis of liver, heart disease, diabetes as well as leads to absenteeism, road traffic accidents and various mental health and behavioural problems.

Alcohol is one of the leading causes of death and disability globally and the same is true for our country India. A total of 3.2% of deaths worldwide are caused by alcohol every year. As per World Health Organization One fourth to One third of male population drinks alcohol in India and neighbouring south Asian countries and the use amongst women in increasing.

Alcohol Use Disorder is the continuous use of alcohol despite evidence of harm and repeated attempts to cut down the use.

It includes tolerance to alcohol which means higher amount is needed progressively to have the same effect and a characteristic cluster of mental and behavioural symptoms appearing when one does not take alcohol i.e., withdrawal.

Alcohol use disorder results in harm and damage to one’s physical and mental health, affects one’s functioning at work and results in relational conflicts and social and legal problems.

Prevalence and extent of problem in India:

Alcohol use is quite common in India both in rural and urban areas with prevalence rates as per various studies varying from 23% to 74% in males in general and although it’s not that common in females but it has been found to be prevalent at the rate 24% to 48 % in females in certain sections and communities.

In 2005 the estimated numbers of people using alcohol in India was 62.5 million with 17.4 % of them (10.6 million) having alcohol use disorder and of all hospital admissions in India 20-30% are due to alcohol related problems.

 

Remember: Alcohol drinking can be a mental health disorder

Alcohole addiction

Alcohole addiction

Please remember that if you or anybody around you is struggling with the inability to contain the alcohol use and consequently facing a lot of problems on all fronts because of alcohol use consider taking him for treatment as it is a mental health disorder which can be treated by proper treatment and compliance.

Road Traffic accidents: In India as per a government report almost 1,34,000 people died in road accidents in 2010, a staggering figure of 336 persons dying daily and a study by alcohol and drug information centre(AIDC) India has revealed that 40% of road traffic accidents occur under the influence of alcohol. Majority of such persons are young and are in the productive age group of 20-50 years, making drunken driving a menace for our country.

Crime and alcohol: Various studies worldwide have reported a strong association between alcohol use and indulgence in high risk behaviour, domestic violence, high risk sexual behaviour, crime and violent acts.
Suicide: Almost 10-15% of people with alcohol related problems commit suicide which is markedly high as compared to general population and hence significant number of lives can be saved if it can be managed early and appropriately.

Coexisting with and making them worse: Alcohol use disorder is frequently associated with other substance use disorders, antisocial personality disorder, anxiety disorders, mood disorders like depression and bipolar disorder and usually the combination becomes complex and difficult to manage. Apart from it alcohol use can lead to alcohol induced psychotic disorder, alcohol induced mood disorder, alcohol induced anxiety disorder and alcohol induced sexual dysfunction.

Drinking makes you fall asleep is a myth: Usually people take alcohol thinking it as a good sleeping aid, but here it should be noted that although alcohol can make it a bit easier to fall asleep it actually disturbs the sleep architecture resulting in decrease in deep sleep and fragmented sleep and ultimately frequent and longer periods of awakening. So refrain from using alcohol as a sleeping pill.

Foetal Alcohol syndrome: The women who drink while pregnant have 35-40% chances of having a baby with defects. Alcohol use during pregnancy results in foetal alcohol syndrome which is a leading cause of intellectual disability in kids in western countries; it includes a baby born with small head, facial deformities and limb and heart defects. So pregnant and lactating mothers should stay away from alcohol to prevent damage to the baby.

References:

 

Sadock BJ, Sadock VA. Alcohol related disorders in Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (10th ed.)390-407. Philadelphia, PA, Lippincott, Williams & Wilkins; 2007.
Saddock B. J., Saddock V. A. (2005) Alcohol related disorders in Comprehensive textbook of Psychiatry (8th ed.) 1168-1188 Philadelphia, PA, Lipppincott Williams & Wilkins
Girish N, Kavita R, Gururaj G, Benegal V. Alcohol use and implications for public health: Patterns of use in four communities. Indian J Community Med 2010;35:238-44
Mohan, D., Chopra, A., Ray, R. and Sethi, H. (2001) Alcohol consumption in India: a cross sectional study. In Surveys of Drinking Patterns and Problems in Seven Developing Countries, Room, R., Demers, A., Bourgault, C. eds, pp. 103–114. World Health Organization, Geneva.
Global status report on alcohol. Geneva: World Health Organization; 2004. 
Obot SI, Room R. Alcohol, Gender and drinking problems: Perspectives from low and middle income countries. Department of Mental health and Substance abuse. Geneva: World Health Organization; 2005.
Shivkumar T, Krishnaraj R. Road traffic accidents due to drunken driving in India-Challenges to prevention. International Journal of Research in Management & Technology (IJRMT), ISSN: 2249-9563 Vol. 2, No. 4, August 2012
Vijayanath.V, Tarachand.K.C. Alcohol and Crime Behaviour. J Indian Acad Forensic Med. July-September 2011, Vol. 33, No. 3
Gururaj G, Girish N, Benegal V, Chandra V, Pandav R. Public health problems caused by harmful use of alcohol – Gaining less or losing more? Alcohol Control series 2, World Health Organisation. New Delhi: Regional Office for South East Asia; 2006
Please click on the links given below for more information
http://www.nhs.uk/Conditions/Alcohol-misuse/Pages/Introduction.aspx
http://www.mentalhealth.com/home/dx/alcoholdependence.html

Symptoms:

Alcohol use disorder manifests with the following symptoms in a person with history of long term usually a year or more of alcohol consumption:

  1. Craving or strong desire to consume alcohol.
  2. The person spends a lot of time in obtaining alcohol and then consuming it and then remaining intoxicated with it and then coming out of its effects on his mind and body.
  3. The person often desires to cut down or tries to reduce the amount of alcohol he/she is consuming but such efforts have been unsuccessful.
  4. The alcohol intake continues beyond the limits set by the person and gradually the amount of alcohol consumed also keeps on increasing beyond what was initially intended.
  5. The person develops “Tolerance” to alcohol that is he/she requires larger amounts to get the same desired effect or intoxication and with the same amount he/she can’t get the same desired effect as he was getting earlier.
  6. This recurrent use of alcohol results in failure to discharge ones duties and role properly in the society for e.g. Absenteeism from work or school, poor performance at work or school, neglecting children and household activities.
  7. This pattern of alcohol use also leads to a lot of interpersonal and social problems or it increases the problems by its effects e.g. arguments and fights with spouse or physical fights with other people.
  8. Because of alcohol use all other important things or recreational activities in the life are given up or reduced and the person totally withdraws himself to alcohol use.
  9. Despite knowing the damage alcohol is doing to a person’s health, social or interpersonal life, the consumption is continued.
  10. The person consumes alcohol recurrently in situations where it is physically hazardous to use alcohol e.g. driving

Withdrawal symptoms

The person gets “Withdrawal symptoms” whenever he/she doesn’t take alcohol. It can include one or more of the following:
a. Tremors
b. Sleep disturbance
c. Mood changes
d. Sweating
e. Anxiety
f. Seizures (Fits)
g. Disorientation
h. Hallucinations (sensation without a stimulus e.g. feeling insect crawling on the skin though there are none)
i. Increased blood pressure
j. Delirium (a state of fluctuating consciousness)
k. Intense craving for alcohol

Alcohol intoxication

Alcohol being a psychoactive substance results in varied effect on a person depending on the quantity ingested and tolerance of the person.

Depending on the amount ingested alcohol intoxication can result in euphoria, flushed skin, decreased social inhibition at lower dosage to nausea and vomiting, slurred speech, impairment of balance, muscle coordination and impaired decision making ability, severe breathing difficulty to coma and death at progressively higher dosage.

References:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Clinical Description and Diagnostic Guidelines. The ICD-10 Classification of Mental and Behaviour Disorder. Geneva, Washington DC: WHO; (1992). WHO.
Sadock BJ, Sadock VA. Alcohol related disorders in Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (10th ed.)390-407. Philadelphia, PA, Lippincott, Williams & Wilkins; 2007.
Saddock B. J., Saddock V. A. (2005) Alcohol related disorders in Comprehensive textbook of Psychiatry (8th ed.) 1168-1188 Philadelphia, PA, Lipppincott Williams & Wilkins
Please click on the links given below for more information
http://www.nhs.uk/Conditions/Alcohol-misuse/Pages/Diagnosis.aspx

http://www.mentalhealth.com/home/dx/alcoholdependence.html

Causes

Multiple factors contribute in a complex way right from the initiation of alcohol to the development of a full blown alcohol use disorder.

In general it is a combination of psychological, biological, socio-cultural and several other factors resulting in the development of severe repetitive alcohol related life problems.

The initial intake or initiation of alcohol is largely determined by social, religious and psychological factors and genetic factors might also contribute to that.

It is estimated that a series of genetic influences are responsible for almost 60 percent of the risk for alcohol use disorder while the rest is determined by the environmental factors.

Psychological factors include use of alcohol to reduce stress and to self medicate to relieve psychological pains and nervousness; however it should be remembered that in the long run and at higher dosage especially with falling blood alcohol levels it rather increases the feeling of nervousness and tension.

While psychodynamic theories suggest fixation at oral stage and using alcohol to deal with harsh punitive super ego, the behavioural school suggests expectations of rewarding effects and positive reinforcement as reasons for maintenance of drinking behaviour.

Socio cultural factors include the cultural attitude towards drinking, drunkenness and personal responsibility for consequences as important determinants of alcohol use disorder.

Childhood factors like history of attention deficit hyperactivity disorder, conduct disorder or both increase the likelihood of alcohol use disorder later.

Studies have shown a characteristic biological pattern of brain functioning in children at high risk of alcohol related disorders.

Genetically the close relatives of an alcoholic person have three to four fold higher risk of having severe alcohol related problems.

So we see how various biological, psychological, socio-cultural factors interact to produce alcohol use disorder in a person.

References:

Sadock BJ, Sadock VA. Alcohol related disorders in Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (10th ed.)390-407. Philadelphia, PA, Lippincott, Williams & Wilkins; 2007.
Saddock B. J., Saddock V. A. (2005) Alcohol related disorders in Comprehensive textbook of Psychiatry (8th ed.) 1168-1188 Philadelphia, PA, Lipppincott Williams & Wilkins
Reich T1, Edenberg HJ, Goate A, Williams JT. Genome-wide search for genes affecting the risk for alcohol dependence. Am J Med Genet. 1998 May 8;81(3):207-15.
Hawkins JD, Graham JW, Maguin E, Abbott R, Hill KG, Catalano RF. Exploring the effects of age of alcohol use initiation and psychosocial risk factors on subsequent alcohol misuse. Journal of Studies on Alcohol. 1997;58(3):280–290.
Pillai A, Nayak MB, Greenfield TK, Bond JC, Nadkarni A, Patel V. Patterns of alcohol use, their correlates, and impact in male drinkers: a population-based survey from Goa, India. Social Psychiatry and Psychiatric Epidemiology. 2013;48(2):275–282.
Knibbe RA, Joosten J, Choquet M, Derickx M, Morin D, Monshouwer K. Culture as an explanation for substance-related problems: a cross-national study among French and Dutch adolescents. Social Science and Medicine. 2007;64(3):604–616.
Please click on the links given below for more information:

http://www.nlm.nih.gov/medlineplus/ency/article/000944.htm

http://pubs.niaaa.nih.gov/publications/Social/Module2Etiology&NaturalHistory/Module2.html

Diagnosis

Alcohol use disorder can be diagnosed clinically by detailed history both from the patient and close informants and care takers; mental status examination and physical examination for signs of alcohol intoxication or withdrawal and some investigations may also help for e.g.

  • Level of alcohol in the blood if intoxication is suspected.
  • Raised live enzymes especially GGT and SGOT, SGPT
  • Stigmata of long term alcohol use e.g. Changes in liver including fatty liver or cirrhosis.
  • Portal hypertension or Varices with history of alcohol use.
    References:
    American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
    Clinical Description and Diagnostic Guidelines. The ICD-10 Classification of Mental and Behaviour Disorder. Geneva, Washington DC: WHO; (1992). WHO.
    Sadock BJ, Sadock VA. Alcohol related disorders in Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (10th ed.)390-407. Philadelphia, PA, Lippincott, Williams & Wilkins; 2007.
    Saddock B. J., Saddock V. A. (2005) Alcohol related disorders in Comprehensive textbook of Psychiatry (8th ed.) 1168-1188 Philadelphia, PA, Lippincott Williams & Wilkins
    Please click on the link given below for further information:
    http://www.nhs.uk/Conditions/Alcohol-misuse/Pages/Diagnosis.aspxManagement
    Alcohol use disorder is a complex disorder requiring a multi-pronged strategy to deal with it.
    Management usually comprises of three steps:
    1.Intervention
    2.Detoxification
    3.Rehabilitation
    This approach assumes that the person has already received all possible medical care for physical and mental consequences of alcohol use, for e.g. if the person has severe liver disease, or internal bleeding secondary to alcohol use then first he/she should be hospitalized and liver disease or internal bleeding should be treated along with the management of withdrawal symptoms.
    1. Intervention: In this phase the person is confronted with the consequences of his alcohol use and resulting problems to break denial and improve motivation for treatment and abstinence.
    Family members are made to understand that they should not protect the patient from the problems caused by alcohol also they are provided with insight and understanding to recover from the guilt, fear and anger they often harbour. They are also encouraged to meet support groups if any available.
    2. Detoxification: Includes thorough physical examination and then based on the severity of withdrawal symptoms medication is provided along with rest, adequate nutrition and vitamins especially thiamine.
    Studies have shown that people who receive substance abuse treatment have better outcomes and chances of remaining abstinent than those who do not.
    3. Rehabilitation: In this phase emphasis is on maintaining high levels of motivation for remaining abstinent from alcohol and the patient is helped to adjust to a new life style free of alcohol and continued efforts are made to prevent relapses.
    The following management strategies are used in various phases:
    A. Medications:
    Benzodiazepines (BZDs)
    Lorazepam, Chordiazepoxide are used in the detoxification phase to relieve withdrawal symptoms.
    They are habit forming drugs and have abuse potential so they should be used in the short term under specialist supervision only.
    Thiamine and other Vitamines: It is very important to replenish these vitamins in the detoxification phase as otherwise it can result in short term or long term damage to brain resulting in some severe brain disorders.
    Anti craving medicines: These are medicines which are supposed to reduce the desire to take alcohol and hence may aid in rehabilitation phase to maintain abstinence. Some of these are approved for this purpose and for some evidence is growing up. These are not habit forming medicines and should only be taken under specialist guidance.
  • Acamprosate
  • Naltrexone
  • Topiramate
  • Baclofen
    Alcohol deterrent (Disulfiram): Should only be used in Rehabilitation phase under specialist guidance after appropriate gap between alcohol cessation and its initiation otherwise it may cause a severe reaction with the alcohol in the body and may lead to hepatitis, loss of vision, peripheral neuropathy to respiratory failure and death.
    B. Psychotherapy & counselling: Focuses on utilizing various techniques to help the patient maintain abstinence, help him/her with day to day issues, helping to adjust with an alcohol free life style and strengthen the resolution by discussions of consequences of alcohol and how healthy coping skills can be developed to deal with life problems and slips and staying away from alcohol. The therapy can be done in individual or group sessions.
    C. Cognitive behavioural therapy: This form of psychotherapy is showing effectiveness in the treatment of Alcohol use disorders especially when it is co-morbid with depression and it involves the therapist using various techniques to help the patient understand and manage the factors that contribute to their Alcohol use disorder as well as depression. Cognitive errors are corrected and behavioural techniques are used to reduce or stop undesired behaviour and relaxation techniques like deep breathing are used to control the bodily manifestations of Alcohol use disorder and depression.
    D. Supportive psychotherapy: In this psychotherapeutic approach a variety of psychotherapeutic techniques are used to foster a healthy mental state in the patient through a supportive therapeutic relationship with the patient.
    E. Family therapy: Family psychotherapy can help family members better understand their loved one’s alcohol use disorder and learn new ways of communication and interaction that do not reinforce the alcohol seeking behaviour and associated dysfunctional behaviours and this in turn ensures treatment compliance and improves the outcome.
    F. Group therapy: In this the psychotherapy is done with a group of unrelated individuals all having Alcohol use disorder and it’s a very useful way of providing effective treatment and generating support.
    Self-help groups like alcoholic anonymous can also provide the much needed support and strength and learning from experience sharing and by observing the alcohol free life style of a sober peer group.

References:

Sadock BJ, Sadock VA. Alcohol related disorders in Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (10th ed.)390-407. Philadelphia, PA, Lippincott, Williams & Wilkins; 2007.
Saddock B. J., Saddock V. A. (2005) Alcohol related disorders in Comprehensive textbook of Psychiatry (8th ed.) 1168-1188 Philadelphia, PA, Lipppincott Williams & Wilkins.
Raistrick, D and G Tober 2004, Psychosocial interventions. Psychiatry 3(1): 36-39.
Albert J. Arias, Henry R. Kranzler. Treatment of Co-Occurring Alcohol and Other Drug Use Disorders. Alcohol Res Health 2008; 31(2):155-67.
Dutra L, Stathopoulou G, Basden SL, Leyro TM, Powers MB, Otto MW. A meta-analytic review of psychosocial interventions for substance use disorders. Am J Psychiatry. 2008; 165:179–187.R. Kathryn McHugh, Bridget A. Hearon, and Michael W. Otto. Cognitive-Behavioral Therapy for Substance Use Disorders. Psychiatr Clin North Am. Sep 2010; 33(3): 511–525.
Please click on the links given below for further information

http://www.nhs.uk/Conditions/Alcohol-misuse/Pages/Treatment.aspx

http://pubs.niaaa.nih.gov/publications/AA81/AA81.htm

Prevention

The prevention of alcohol related problems lies in:

  • Greater awareness about the harmful patterns and effects of alcohol use and that it can be a mental health disorder.
  • Better role modelling by parents and society at large regarding alcohol use.
  • Early recognition of problem behaviour in teens which may herald the starting up of alcohol or substance use like:
    a. Lack of coordination or slurred speech.
    b. Falling grades in school.
    c. Withdrawn behaviour and lack of interest in activities.
    d. Relationship issues.
    e. Frequent mood swings and irritability.
    Early intervention: Seek psychiatric help if you or anyone around you is struggling with alcohol use and consequent problems due to it or if you or anyone around you is using alcohol to self-medicate for some other emotional or behavioural issues like stress or depression.
    Remember research has shown that if you start alcohol when the brain is still growing up like in teenage years you have higher chances of developing alcohol use disorder.
    So the early the intervention the better the outcome.
    Seek help…Quit alcohol… embrace life!!The content of this module has been authored by Dr Madhusudan Singh Solanki,

 

 

International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD 10) Version for 2010

Chapter V : Mental and behavioural disorders (F00-F99)

Mental and behavioural disorders due to psychoactive substance use (F10-F19)

F10Mental and behavioural disorders due to use of alcohol

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